Exclusive: The DHS National Biosurveillance Integration Center – Ready or Not, Opening September 30th

by DR. ROBIN MCFEE September 30, 2008

The United States faces the potential of biological threats that occur naturally or may be the result of terrorism. Threats of bioterrorism have drawn attention to the need for early detection and warning - often referred to as biosurveillance systems.

In response to the threat of bioterrorism and naturally occurring epidemics that threaten national security, the Department of Homeland Security (DHS) plans to unveil its center for combating bioterrorism today. While this may be another step forward in national preparedness, there remain important issues to be addressed. Both the Government Accountability Office (GAO) and DHS' own Office of Inspector General as well as a Congressional reports all express significant concern about the National Biosurveillance Integration Center (NBIC), across several domains.

Last February (2008) report of the DHS' Office of the Inspector General (OIG) supports the July 2008 GAO and July 2007 DHS OIG reports on the federal effort to coordinate and consolidate the various means of detecting a biological event - natural or man- made. According to the reports, since the anthrax events of 2001 and 9/11 nearly $32 billion has been spent on bio-defense and biosurveillance, and to date there is less than optimal coordinated effort to integrate the data gathered from local, state and federal agencies into anything resembling intelligence.

The 9/08 Majority Party report from the Congressional Committees charged with oversight has been aggressive in its criticism of DHS and the NBIC, stating it has achieved "little progress." Paul Schneider, Deputy Secretary of DHS disagrees in a 9/10/08 commentary on Congress's review of DHS performance relative to the 9/11 Commission. "The report states that there has been "little progress" with respect to Section 1101, which requires an operational National Biosurveillance Integration Center (NBIC) by September 30, 2008. In fact, NBIC is now operational, fully satisfies the statutory requirements, and recently disseminated a report on a salmonella outbreak." While the report of the salmonella outbreak is all well and good, outbreak reports have been reported in the past without DHS assistance. So the question that needs to be asked - today is "opening day" - what does that mean in real time preparedness? Right now, probably not much.

"The greatest threat to mankind's continued existence is the virus"

Joshua Lederberg, Nobel Laureate

It is always nice to start off an article with a happy thought. Especially considering the potential for widespread death if the avian flu virus were to evolve into a pathogen similar to the one causing the Spanish Flu Pandemic of 1918. At least 20 million would be expected to die if a new pandemic occurred, although some estimates raise that to above 50 million human lives lost. Today avian flu still kills a high percentage of those infected. Is it any wonder with antimicrobial resistance on the rise, emerging diseases associated with mans encroachment of previously undisturbed regions and numerous biological weapons labs worldwide , that virtually every bioterrorism, infectious disease, and emergency preparedness professional considers the United States vulnerable to emerging pathogens, biological weapons and terrorism.

Well consider this - it is 7 years after the anthrax attacks of 2001 and the Department of Homeland Security (DHS) is now, repeat now opening their National Biosurveillance Integration Center (NBIC) in spite of the fact it is not adequately ‘integrated' with other data sources or agencies vital to biosurveillance, nor is it fully operational given "operational" has yet to be adequately defined by DHS! At least according to the GAO and the OIG. Recall the recent announcement by DHS that a new program is being developed to restrict access to radioactive materials - cesium found in medical and research facilities? That it has taken DHS 7 years to address securing easy access radioactive materials (never mind that it won't be implemented until 2009), and 7 years for the long awaited but incompletely functional DHS biosurveillance center - these do not inspire confidence.

Bioterrorism Preparedness

What does national preparedness mean? It suggests the ability to respond to a wide array of threats and prevent unnecessary loss of life or injury. This requires translating national policy initiatives into local program implementation. It is a significant challenge to prepare for an unknown event, especially without a clear cut indicator of who and how many to protect, and from whom.

National activities to prevent or respond to a bioterrorism event have hinged largely on the development of biosurveillance programs and arms length detector technologies.

Biosurveillance is a term that describes the monitoring of characteristics - symptoms, lab results or outcomes (death) within a population, for changes that could indicate an emerging threat - natural or manmade - such as exposure to a pathogen, chemical or toxicant. Examples include mandatory reporting of cases of selected infectious diseases such as plague, rabies, anthrax, or influenza as well as outcomes data such as numbers of deaths in a given period of time related to influenza or pneumonia, to name a few. To date, most surveillance has not been real time, instead the result of patient or community information submitted to local health departments which then aggregate and in some cases analyze and then submit to state or federal health agencies. In the aftermath of the anthrax attacks of 2001, instead of just waiting for cases to appear, it became clear that identifying trends such as number of patients complaining of respiratory symptoms, or increases in the purchase of over the counter cold remedies, or number of children accidentally ingesting parent's cough medicines could be complementary to case identification and allow for earlier recognition of a possible epidemic or bioterrorism event. As a result of this realization, various local and state data sources are being accessed - poison control centers, health departments, hospitals, and other organizations. The data are transmitted mostly to federal agencies - largely the CDC.

It became readily clear in 2001 and 2002 that the system of surveillance was antiquated and slow; it wasn't capable of identifying the health risks until well after an attack had taken place. The CDC, Department of Defense and Department of Homeland Security determined it was necessary to begin monitoring regional and consolidated biosurveillance data and trends to see the "big picture" in real time. It was felt that public safety and public health data should be monitored on the local level as well as sent to a centralized repository for aggregation into larger geographic areas to detect a multi site concurrent attack instead of the current silo mentality of looking at things agency by agency or locality by locality.

Biosurveillance initiatives since 9/11

While it can be argued that the DHS biosurveillance center was only mandated by the 9/11 Commission and the resulting law that took effect in 2007 and thus it is understandable there might be some kinks to work out on the maiden voyage this week, consider that the military and CDC had embarked upon biosurveillance systems several years ago, and that in the aftermath of anthrax, SARS, monkeypox, avian flu, West Nile Virus and other worrisome threats their sense of urgency, along with federal funding, catalyzed national surveillance programs. The DoD and CDC recognized the critical importance to unify the fragmented approach to syndromic surveillance and create sentinel data acquisition systems that looked for emerging trends that could be analyzed on a broad scale, not lost in isolation as is often the case.

One of the early federal government programs designed for syndromic surveillance was initiated in 1997 as a military program. The DoD in establishing their electronic medical record system, created a data analysis project which tied in military health care providers worldwide and stored information about active duty personnel and their dependents. They established Global Emerging Infections Surveillance and Response System (GEIS) as a "prototype system for early detection of infectious disease outbreaks at military facilities in 1999. A program called "ESSENCE" - The Electronic Surveillance System for the Early Notification of Community Based Epidemics takes every patient encounter from ambulatory care data - and those patients that are coded in certain monitor categories trigger evaluation and analysis. While most syndromic systems monitor pre-diagnostic data, ESSENCE monitors data during diagnostic encounters. The value is clear - instead of just looking at symptoms - important though they are the ability to review diagnosis - especially noting trends in severe respiratory cases adds an important dimension to human biodata analysis.

In the aftermath of anthrax 2001, the federal government, through CDC, started to improve the level of readiness in local and state health departments. One such initiative was to stimulate a proliferation of syndromic surveillance systems in these departments. CDC then designed and managed the BioSense program which sought to bring the decentralized local health department data into a centralized national analysis center.

Enter DHS.

The 9/11 Commission recommended the creation of a National Biosurveillance Integration Center (NBIC), which was included in the Implementing Recommendations of the 9/11 Commission Act of 2007. This Act requires that DHS ensures NBIC has the ability to "rapidly identify, characterize, localize and track a biological event of national concern" with the goal being real time or near real time. (Sounds like the mandates for the DoD and CDC programs). The (bioterrorism) threat presents a risk to the population, economy or infrastructure of the United States. Section 1011 of the Act requires NBIC to operate by "integrating and analyzing data relating to human health, animal, plant, food and environmental monitoring systems" and must be fully operational by September 30, 2008. According to NBIC, their strategy to ensure that national biosurveillance information is integrated, the following agencies were considered critical and should be represented - DHS, Department of Commerce (DOC), Department of Defense (DOD), Environmental Protection Agency (EPA), Department of Health and Human Services (HHS), Department of the Interior (DOI), Department of Justice (DOJ), Department of State (DOS), Department of Transportation (DOT), The U.S. Postal Service (USPS), Veteran's Administration (VA), as well as state, local, private sector and international partners.

In response to the 2007 law, the Department of Homeland Security is developing two initiatives to enhance national preparedness - The National Biosurveillance Integration Center (NBIC) and the BioWatch program. NBIC is intended to be a center where information on biological events can be integrated and coordinated. BioWatch will operate systems and detectors nationwide, which will be used to test the air for biological agents. Biowatch is working towards developing and acquiring technologies that can provide real time or near real time information about a biological release; it will take at least 1 to 3 years for this to be fully implemented according to the GAO and other experts.

As for the NBIC, according to the GAO, DHS has made progress towards making NBIC operational by 9/30/08 as required by law. But GAO cautions that it is unclear what operations the center will be able to carry out when it opens. Of concern, while DHS has acquired the facilities and hired some staff, they have not defined what capabilities should be used to consider it operational. This is not only problematic for the US in terms of preparedness, but also makes it difficult for the software and other information technology (IT) team to support the project. As one can imagine, not knowing what the ground rules, benchmarks or operational objectives are makes it pretty challenging for management and staff. One would think it might be tough to work at a job where the definitions of "capability" are sketchy. The good news from a confused employee perspective - DHS hasn't fully staffed the center.

In an effort to establish interagency coordination (government speak for cooperation) NBIC is seeking to formalize relationships with the 11 agencies through various mechanism reflected by the following: 1. Memorandum of understanding (MOU) which confirm initial agreement to participate in NBIC as a member agency, 2. Interagency security agreements (ISAs) which formalize the technical exchange of information such as data on human health, between NBIC and the member agency, and 3. Interagency agreements (IAAs) that define programmatic, financial and staffing arrangements between NBIC and the agency. IAA signatory agencies agree to provide detailees to work at NBIC - mostly as subject matter experts and/or liaison guidance with respective home agencies.

Of immediate concern DHS has only signed memoranda of understanding (MOU) with 6 of the 11 above listed agencies. Recall that MOU merely confirm initial agreement to participate as a member agency. These MOU signatories include DOD, Agriculture, HHS, DOI, DOS, DOT. Notably not signatories of MOU include DOC, EPA, DOJ, USPS and the VA. One would think given the anthrax attacks of 2001 involved a variety of Post Offices, the Postal Service might want to sign on with Homeland Security. Given the mail was the ideal delivery system to create panic - what is more fundamental to our daily lives than checking the mail? While this delivery system wasn't the ideal military strategy it was an elegant terrorist tactic. Kill one, scare a million! Isn't the FBI part of DOJ? One would think they might be interested in collaborating on biological preparedness. Where's King Solomon when we need him? Or do we continue with the interagency rivalries - your patient is my crime scene.....your crime scene is my patient? Speak about the need to make a Reese's peanut butter cup and share! Never the less, it should give one pause to wonder why DHS has only implemented 6 MOU, zero ISAs or IAAs as of the GAO report. Let's be clear; many of the men and women working at DHS are dedicated professionals trying to protect our nation amidst the usual government bureaucratic constraints. Giving DHS the benefit of the doubt it is possible additional members have just signed on with MOU as this goes to publication; a few might have even taken the MOU seriously and signed ISAs or IAAs. So what?! One would think all of these cabinet level agencies take their marching orders from the "head of the Cabinet" - the President? If a national biosurveillance capability is in fact as important to President Bush as his HSPD's would suggest, might it not be practical for the Chief Executive to get the respective Secretaries together, offer them a pen and admonish them to "sign it and get it done!"

According to NBIC, one of the challenges is defining the data sharing arrangements with member agencies - interagency coordination to characterize a biological event may require data that NBIC member agencies have not previously shared with other agencies. Making matters worse, according to NBIC concept of operations, the center cannot perform its integration and analytical mission without the subject matter expertise from interagency detailees. As of July 2008, NBIC has secured one detailee. NBIC officials were unable to predict how many additional MOUs, ISAs, IAAs or detailees it will have by today. If an agency charged with anticipating a biological threat cannot even anticipate the potential level of cooperation among "friendly" folks - people also in the business of protecting the US but in different agencies - it doesn't inspire much confidence in the ability of NBIC or DHS to protect us against unfriendly folks.

The foundation for an effective biosurveillance integration center is the ability to obtain information to integrate. A fundamental flaw in NBIC is the clear lack of collaboration among the very agencies and their data vital to analyze. Given DHS was created to lead the fight to protect the nation, one wonders why they are reticent to or incapable of forging alliances?

One also wonders why this project wasn't given more forethought or attention to planning - a sad indictment of a preparedness agency. It seems the approach of "ready, fire, aim" was pursued. An example of inadequate planning is exemplified by NBIC not having all the interagency security agreements in place with member agencies, according to a government report. In a performance culture governed by the terms "classified" and "top secret" wouldn't it dawn on the team that security clearance for information sharing might be an important consideration and part of the planning phase for the center?

Consider the fact that additional work must be done by IT before NBIC can even grant full access to member agencies. Clearly not much advanced preparation occurred if a contractor DHS hired to enhance NBIC IT capability delivered the upgrade in April but the additional work needed to complete the system has yet to be done. Making matters more complicated - NBIC analysts have not been trained to use the latest IT; member agencies will not have full access to interagency collaborative functions until the analysts are trained and the IT fully implemented - likely sometime in 2009! So why even have member agencies send folks if they can't get the info? They can share it of course, but then only if they sign on. Feel like you are going in circles? Sound like another government operation?

NBIC continues to have problems with some fundamental tasks, including establishing a definition of what capabilities the center will provide once it is considered fully operational. NBIC has drafted planning documents to define their capabilities according to the GAO report. How effective an organization will be when it can't define what capabilities define the operation of their organization - remains to be seen. Confused? Join the club! In all fairness the 9/11 Commission Act of 2007 does not define what capabilities NBIC needs to have in place by September 30th either. Speak about telling someone that they have to "do it" but not defining what the "it" is! DHS and NBIC have been working on a draft of expected operational capabilities and functions, state of the IT system, personnel expectations, analytic capabilities and some specifics in terms of goals, objectives, milestones, standard operating procedures and cost estimates since the GAO investigation and report appeared. Call me crazy but don't you define these before you start the enterprise? Only in government can you create an organization, get the facility, blow through the initial investment money and then decide what kind of organization you are going to be. Does it surprise anyone that NBIC recently requested an additional $4.2 million from DHS? This represents a 50% increase over the $8 million it supposedly had available in fiscal 2008. Expect requests for more money. Though it will pale to insignificance the amount Wall Street will get this week.

It's not as if this was dreamt up in 2007 with a short turnaround time. DHS has been involved with some form of biosurveillance for several years. In 2004 Homeland Security Presidential Directive 10 directed DHS to coordinate all of the disparate biosurveillance programs that have arisen since 9/11. As a response, DHS Science and Technology Directorate began the National Biosurveillance Integration System. In January 2005 the NBIS was transferred to the Information Analysis and Infrastructure Protection Directorate (IAIP). Experiencing some setbacks and reorganization in IAIP which left NBIS to be placed in the Preparedness Directorate (PD) where it was given lower priority. In 2005 was given higher priority but then moved into the Office of the Chief Medical Officer (CMO). Then the Office of Health Affairs was created in DHS so NBIS was moved again.

The problem doesn't rest solely on the shoulders of DHS. Every agency, every performance culture has unique missions and operating protocols. In addition, under the umbrella of preparedness remains competition for funding, power and preeminence. We may all be on the same team, but there is no "team" in the word "I" and the sad reality, competition among agencies persists. The non participating agencies should be asked why they aren't on board. The CDC, an agency within the Department of Health and Human Services (HHS) has its own program called BioSense which collects information. CDC also works closely with the local and state reporting agencies, funds major initiatives with million dollar plus grants, and is considered the civilian "go to" team for biosurveillance and disease response. In fact over the years they have created their own network of biosurveillance centers of excellence. Worth noting, the White House put HHS in charge of biosurveillance efforts in 2007 under Homeland Security Presidential Directive 21 whereby HHS has authority over the response to health emergencies and to field a system that creates a networked system that allows for two way information flow between and among federal, state and local government public health authorities and clinical health care providers. Initially it was unclear whether DHS or HHS would be in charge. One still wonders in spite of the money and effort expended to create the NBIC in DHS. In case this isn't frustrating enough, consider much of the data transmitted is operator dependent - that is, if the local official thinks there is value in doing so they send it, if not, they don't! Garbage in, garbage out.

Consider this. During a winter flu season three major cities within 100 miles of each other report flu and pneumonia deaths to the 122 Cities Mortality Reporting System, a program of biosurveillance that incorporates data from 122 key cities nationwide. One city consistently didn't' report deaths for a period of several weeks while the others, equally matched demographically, report several deaths. No one at CDC seemed to notice this oddity - the unlikely nature of the data. One observant epidemiologist did in the region, and called the city health agency and state health office - the folks there didn't think it was worth submitting the data, so they didn't. One could argue that critical information was withheld- information that could have resulted in increased medical care to an area that did have numerous flu deaths. But then one could argue that the federal folks - CDC - who were supposed to interpret the data, never noticed an odd trend. Given CDC data will go to NBIC and that most data are dependent upon the sender - a clear vulnerability in our biosurveillance system, NBIC notwithstanding.

Part of the problem stems from the fragmented health system in the US. Unlike the United Kingdom which enjoys near universal electronic medical record (EMR) capture of patient information - making data acquisition and analysis significantly easier than in the US which does not have nearly the penetration of EMR, data integration is very difficult in our operator dependent system. It is well known many health departments have inadequately trained personal, are resource strapped and with inconsistent IT capability.

On the most fundamental level of biosurveillance - the epidemiologic capacity in state and territorial health departments - based upon several evaluations, it remains inadequate. The response capability of local health departments is inconsistent at best; many health departments are understaffed, have inadequate resources, often lack highly trained expertise and at times have been the weak link in a national surveillance chain.

Where do we go from here?

First - with respect to the project "NBIC" let's get it done. Put some products on the shelf and prove you are open for business. To date, regardless how we parse "meeting statutory expectations" the fact is the NBIC is not fully operational and that was the intent of the legislation. This isn't a semantics game; the job is to protect the US. The goal is to identify an emerging biological threat - whether natural or intentional. Given NBIC is behind schedule, this of course sets the stage for going over budget, beyond the fact it delays the functional response capacity of a vital asset to protect the United States.

The NBIC faces enormous challenges if it is to become a useful entity instead of another funded project under the heading of "preparedness." These include identifying why all 11 agencies haven't signed on, addressing the problems and getting everyone on board. The National Center is incomplete without its members signing on. Assuming we agree creating the NBIC is of value, finish the IT problems, sign on the members and get going. The start of flu season is a month away. This would be a good time to test the system!

Unless of course you believe it is another redundant system, competing with the other preexisting biosurveillance systems - one run by the Department of Defense (DoD) and one by the Centers for Disease Control and Prevention (CDC). Then why reinvent the wheel? Cut our losses, retask the folks to another biosurveillance program and work on improving what you have. On the other hand, redundancy isn't necessarily a bad thing if each entity is operational, has clear objectives, is interoperable with the other programs and provides valuable work products that identify a threat that might otherwise go unnoticed in the absence of the project or center. The DoD, CDC and NBIC can complement each other. NBIC is worth supporting.

From a preparedness perspective, the federal government is missing an important point - the value of the community clinician to identify the sentinel, index or first case of a dangerous biological event or emerging pathogen. While no one should argue that biological data - from animals, humans, agriculture and worldwide should be submitted to a national analysis center to identify trends and provide actionable intelligence as well as raise the alarm or send out highly skilled response teams, the historical reality is simple. Outbreaks are identified when someone or some animal gets sick, and that identification rests squarely upon the initial diagnostic acumen of the physician, or veterinarian. No lab result can replace the insight of a skilled diagnostician; especially if no illness is suspected and no tests are ordered! Consider this - it was an astute infectious disease physician in private practice and a well trained laboratorian that diagnosed the first case of inhalation anthrax - NOT public health, not an analyst reading over syndromic information. The process never would have been started had it not been for the insight of the physician working closely with the laboratory. Once the presumptive diagnosis was made, then the cascade of response that resulted in the CDC arriving to investigate was initiated. Same is true for other cases in the Northeast - someone in the clinic or emergency department had to suspect an unusual illness was occurring before any labs, or medical records - the basis for biosurveillance data - was initiated.

As such it is important to recognize there is limited surge capacity nationwide among our emergency departments and health care facilities is one of the major vulnerabilities to biopreparedness. Overcrowding is tantamount to creating a breeder for germs! And it also limits the time per patient - often the critical difference between making and missing the diagnosis. Recent studies suggest less than a fraction of travel related illness is diagnosed as such in the emergency department; such missed diagnosis can compromise the front line of preparedness. Though beyond the purview of DHS, never the less, the health care system needs repair badly.

Physicians and nurses are overstretched. Health care professionals must function in a world of competing demands against a backdrop of limited resources. In the aftermath of 9/11 federal preparedness funds were provided to enhance the training and response capacity of health care facilities and emergency responder agencies nationwide. Unfortunately with the dwindling of funding comes a reduction of preparedness. Clinicians are interested in bioterrorism preparedness but in the absence of federal leadership (money, regulatory oversight, accountability) our capabilities to identify the sentinel case may erode. So while the NBIC is a good idea, especially if it can provide a wide array of data for analysis that leads to rapid response, if we don't continue to upgrade our local capacities, provide funding, ongoing training as well as best practices leadership from the federal government we will lose whatever gains were enjoyed since 9/11. It is critical that the federal government insist health care facilities, and local preparedness agencies upgrade their plans, and practice them regularly, not just annually and in the most artificial manner which unfortunately is the reality.

In the 21st century, it is beyond the pale for the American health care system to NOT be on universal electronic medical records. In the UK, like the US Military, patient encounters are in electronic format - whether TRICARE or overseas. Shouldn't the US civilian medical system catch up? It will take leadership from the stakeholders and financial support given many clinics and practices desire these IT advances but do not have the funds or expertise to do so. Under the auspices of preparedness, the federal government can take a leadership role.

Also missing from the NBIC is the list of regional and local players that will be invited to and necessary for the center to fully function. According to the GAO report, they will be added on later. The late speaker of the House, Tip O'Neil once opined "all politics is local." So is preparedness. The last folks to be signed on apparently are going to be local agencies. Might want to accelerate that process!

Deputy Secretary Schneider of DHS suggests that "it is unfortunate that the report ignores Congress's failure to implement one of the most important recommendations of the 9/11 Commission. That bipartisan body recommended that Congress "create a single, principal point of oversight and review for homeland security." With more than 80 committees and subcommittees often imposing inconsistent obligations on DHS, Congress has made it exceedingly difficult to prioritize tasks in a manner that best reduces overall risk to the country. While the Department's employees work to implement the 250+ requirements of the 9/11 Recommendations Act, on top of the hundreds of pre-existing legal obligations, Congress would do well to heed the one recommendation directed toward reducing the fragmented congressional oversight."

While he may be right in terms of the number of Congressional committees DHS must answer to, consider the recent Wall Street and banking debacle that is being shouldered by the American taxpayer. The same Congressmen and women, Senators and Representatives, democrat and republican alike - they were supposed to oversee the process. There were far fewer committees and subcommittees - similar to what Mr. Schneider suggests would be attractive, and the lack of oversight and accountability failed the public trust. Instead the Congressional folks superimposed their ideology onto regulatory issues - using their position for social engineering or profiteering. Congress did not hold the cabinet level agency responsible for this industry to be accountable, nor did the Congressional committees themselves uphold the moral and ethical standards as well as obligation to the public to protect. Congress and the leadership in the Department of Treasury failed to protect the public good. As a result, while continuously burdensome and regrettably partisan, the division of power established by the Framers and Founding Fathers centuries ago should continue. They did not trust government, nor the people elected to serve therein; perhaps a good reminder to the 21st century that a wider array of eyes and ears may be the only solution.

We the public need to take a greater interest in our government activities in general and our own community and personal preparedness specifically. Flu season is fast approaching - get a flu shot. Find out what committees your representatives serve on and become proactive. Engage them with concerns. Our government requires the assent of the public and as such we are the final oversight committee. Get more involved in local preparedness planning.

The Department of Homeland Security has made progress in protecting the United States. It is a daunting task to protect an open society. The critical and dynamic balance between security and liberty must be constantly protected. If we lose the very spirit of our great country for the sake of an ill defined benefit of some degree of security, the terrorists win.

DHS has bureaucratic challenges to overcome. NBIC opens today. The concept behind the program is sound. The agencies identified to participate are appropriate. They are not yet fully with the program. If government agencies tasked with some aspect of national preparedness - whether ensuring criminal/terrorist investigation, healthy food, good economy, disease prevention or security cannot collaborate, get acquainted with the performance culture of colleagues and learn what each is capable of in an emergency, we are all in trouble when a bioemergency occurs. When it hits the fan that is not the time to exchange business cards.

Robin McFee is a physician and medical toxicologist. An expert in WMD preparedness, she is a consultant to government agencies, corporations and the media. Dr. McFee is a member of the Global Terrorism, Political Instability and International Crime Council of ASIS International. She has authored numerous articles on terrorism, health care and preparedness, and coauthored two books: Toxico-Terrorism by McGraw Hill and The Handbook of Nuclear, Chemical and Biological Agents, published by Informa/CRC Press.

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